APPLICATION FEES ARE NON-REFUNDABLE OFFICIAL USE ONLY - FEE $100.00 ______
BOARD OF OSTEOPATHIC MEDICAL EXAMINERS
New Mexico Regulation and Licensing Department
BOARDS AND COMMISSIONS DIVISION
Toney Anaya Building ▪ 2550 Cerrillos Road ▪ Santa Fe, New Mexico 87505
505.476.4622 fax 505.476.4665
I. APPLICATION FOR LICENSE FOR OSTEOPATHIC PHYSICIAN ASSISTANTS
I hereby make application for a license to practice as an Osteopathic Physician Assistant in the State of New Mexico. I am submitting the following information as the person named in this application. The photograph attached hereto is a true likeness of myself and was taken less than one year prior to the date of this application.
FULL NAME: ______
(LAST NAME)(FIRST NAME)(MIDDLE)(MAIDEN)
BUSINESS ADDRESS:HOME ADDRESS:
______
(STREET)(STREET)
______
(CITY/STATE/ZIP)(CITY/STATE/ZIP)
______
(TELEPHONE NUMBER)(TELEPHONE NUMBER)
DATE OF BIRTH: ______PLACE OF BIRTH: ______
SOCIAL SECURITY NUMBER: ______DEA NUMBER: ______
Have you ever sought or been granted licensure under another name?( ) YES( ) NO
If yes, indicate other names used: ______
______
II. CERTIFICATE OF PHYSICIAN ASSISTANT EDUCATION
This Certifies that ______P.A., entered the program on
(PHYSICIAN ASSISTANT NAME) (DATE MATRICULATED)
At the located in
(NAME OF UNIVERSITY) (CITY & STATE)
The person named attended the required courses of an accredited Training Program for Physicians Assistants and received a diploma conferring the certification of Physician Assistant on
.
(DATE GRADUATED)
(SIGNATURE OF PRESIDENT, DEAN, REGISTRAR)
(TITLE) (DATE)
ATTACH A PASSPORT QUALITY PHOTO
III. EXAMINATION INFORMATION
NCCPA Certification Date NCCPA Number
IV. STATE LICENSES
List all states or provinces in which you have ever held a Physicians Assistant license or permit to practice.
State or Province License Number Date Issued Date Expired
V. EMPLOYMENT
List Locations and dates of previous employment, including present:
DatesLocation (Address, city, state)
VI. GENERAL BACKGROUND
1. Have you ever been charge with or convicted of a federal, state or local statutes? Yes No
2. Have you, during the past five years, had personal or legal problems with alcohol, narcotics,
stimulants or habit forming drugs? Yes No
3. Have you during the past 5 years been treated or hospitalized for mental illness? Yes No
4. Have you ever had any action taken against you for Medicaid, Medicare, or insurance
fraud? Yes No
5. Have you ever surrendered your provider number or the status of a provider for the Medicare
or Medicaid program by any division or agency of any state or federal government? Yes No
6. Have you ever had a Physician Assistant license denied, revoked, suspended or limited
by any state licensing board or province? Yes No
7. Have you ever failed to pass any examination or part thereof, required by any state board
or province for licensure? Yes No
8. Have you ever resigned or withdrawn your application from a hospital staff or professional
medical group? Yes No
9. Have you surrendered hospital privileges, state licenses, controlled substances registration,
or DEA registration after disciplinary cases or investigations were started? Yes No
10. Do you have any malpractice claims, settlements, judgments or medically related lawsuits
against you or pending? Yes No
11. Have you previously applied for a New Mexico Osteopathic Physician Assistant license
or permit? Yes No
12. Are you currently more than thirty days in arrears in payments of amounts required to be paid
pursuant to an outstanding judgment and order for child support in New Mexico or any
other state? Yes No
IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE QUESTIONS
YOU ARE REQUIRED TO SUBMIT AN EXPLANATION ON A SEPARATE PAGE.
VII. AFFIDAVIT
, being duly sworn, deposes and states that the foregoing statements are true and correct.
Applicant
I further solemnly swear that if granted a license for Osteopathic Physician Assistant in the State of New
Mexico, that I shall abide by the laws of the State.
Dated Signed
State of) : County of)
SUBSCRIBED AND SWORN TO before me this day of, 20.
My commission expires:
Date Notary Public Signature & Seal
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